Eff ects of health-system strengthening on under-5, infant, and neonatal mortality: 11-year provincial-level time-series analyses in Mozambique

Background Knowledge of the relation between health-system factors and child mortality could help to inform health policy in low-income and middle-income countries. We aimed to quantify modifi able health-system factors and their relation with provincial-level heterogeneity in under-5, infant, and neonatal mortality over time in Mozambique. Methods Using Demographic and Health Survey (2003 and 2011) and Multiple Indicator Cluster Survey (2008) data, we generated provincial-level time-series of child mortality in under-5 (ages 0–4 years), infant (younger than 1 year), and neonatal (younger than 1 month) age groups for 2000–10. We built negative binomial mixed models to examine health-system factors associated with changes in child mortality. Findings Under-5 mortality rate was heterogeneous across provinces, with yearly decreases ranging from 11·1% (Nampula) to 1·9% (Maputo Province). Heterogeneity was greater for neonatal mortality rate, with only seven of 11 provinces showing signifi cant yearly decreases, ranging from 13·6% (Nampula) to 4·2% (Zambezia). Health workforce density (adjusted rate ratio 0·94, 95% CI 0∙90–0∙98) and maternal and child health nurse density (0∙96, 0∙92–0∙99) were both associated with reduced under-5 mortality rate, as were institutional birth coverage (0∙94, 0∙90–0∙98) and government fi nancing per head (0∙80, 0∙65–0∙98). Higher population per health facility was associated with increased under-5 mortality rate (1∙14, 1∙02–1∙28). Neonatal mortality rate was most strongly associated with institutional birth attendance, maternal and child nurse density, and overall health workforce density. Infant mortality rate was most strongly associated with institutional birth attendance and population per health facility. Interpretation The large decreases in child mortality seen in Mozambique between 2000 and 2010 could have been partly caused by improvements in the public-sector health workforce, institutional birth coverage, and government health fi nancing. Increased attention should be paid to service availability, because population per health facility is increasing across Mozambique and is associated with increased under-5 mortality. Investments in health information systems and new methods to track potentially increasing subnational health disparities are urgently needed

Depression, suicidal ideation, and associated factors: a cross-sectional study in rural Haiti

BACKGROUND: Since the 2010 earthquake in Haiti, there has been increased international attention to mental health needs throughout the country. The present study represents one of the first epidemiologic studies of depression symptomatology, suicidal ideation, and associated factors in Haiti’s Central Plateau. METHODS: We conducted a cross-sectional, zone-stratified household survey of 408 adults in Haiti’s Central Plateau. Depression symptomatology was assessed with a culturally-adapted Kreyòl version of the Beck Depression Inventory (BDI). Multivariable linear and logistic regression models were built using backward elimination, with the outcomes being continuous BDI scores and endorsing suicidal ideation, respectively. RESULTS: The mean BDI score was 20.4 (95% confidence interval [CI]: 19.3-21.5), and 6.13% (N = 25) of participants endorsed current suicidal ideation. Factors associated with BDI scores were: continuous age (adjusted beta [aβ]: 0.14, CI: 0.06-0.22), female gender (aβ: 2.1, CI: 0.18-4.0), suicidal ideation (aβ: 11.1, CI: 7.3-14.9), death in family (aβ: 2.7, CI: 0.57-4.9), and prior life-threatening illness (aβ: 2.6, CI: 0.77-4.5). Education was a risk factor for depression among women but not among men, and employment was a risk factor for both genders. Factors associated with endorsing suicidal ideation were: BDI score (ten point change) (adjusted odds ratio [aOR]: 2.5, CI: 1.7-3.6), lack of care if sick (aOR: 5.5, CI: 1.1-28.6), alcohol use (aOR: 3.3, CI: 1.3-8.2), and ever having been to a Vodou priest (aOR: 3.2, CI: 1.1-9.5). CONCLUSIONS: A large proportion of Haiti’s Central Plateau may be experiencing high levels of depression symptomatology and/or current suicidal ideation. Screening could be conducted in biomedical, religious, and Vodou healing contexts. For prevention, poverty reduction and improved healthcare access are key elements. For treatment, general psychiatric services, psychosocial services for the medically ill and their families, and substance abuse interventions should be explored. Paradoxical associations related to education and employment require further exploration

Tackling the hard problems: implementation experience and lessons learned in newborn health from the African Health Initiative

Background The Doris Duke Charitable Foundation’s African Health Initiative supported the implementation of Population Health Implementation and Training (PHIT) Partnership health system strengthening interventions in designated areas of five countries: Ghana, Mozambique, Rwanda, Tanzania, and Zambia. All PHIT programs included health system strengthening interventions with child health outcomes from the outset, but all increasingly recognized the need to increase focus to improve health and outcomes in the first month of life. This paper uses a case study approach to describe interventions implemented in newborn health, compare approaches, and identify lessons learned across the programs’ collective implementation experience. Methods Case studies were built using quantitative and qualitative methods, applying the World Health Organization Health Systems Strengthening Framework, and maternal, newborn and child health continuum of care framework. We identified the following five primary themes in health systems strengthening intervention strategies used to target improvement in newborn health, which were incorporated by all PHIT projects with varying results: health service delivery at the community level (Tanzania), combining community and health facility level interventions (Zambia), participatory information feedback and clinical training (Ghana), performance review and enhancement (Mozambique), and integrated clinical and system-level improvement (Rwanda), and used individual case studies to illustrate each of these themes. Results Tanzania and Zambia included significant community-based components, including mobilization and sensitization for increased uptake of essential services, while Ghana, Mozambique, and Rwanda focused more efforts on improving the quality of services delivered once a patient enters a health facility. All countries included aspects that improved communication across levels of the health system, whether through district-wide data sharing and peer learning networks in Mozambique and Rwanda, or improved referral processes and systems in Tanzania, Zambia, and Ghana. Conclusion Key lessons learned include the importance of focusing intervention components on addressing drivers of neonatal mortality across the maternal and newborn care continuum at all levels of the health system, matching efforts to improve service utilization with provision of high quality facility-based services, and the critical role of leadership to catalyze improvements in newborn health

Data-driven quality improvement in low-and middle-income country health systems: lessons from seven years of implementation experience across Mozambique, Rwanda, and Zambia.

BACKGROUND: Well-functioning health systems need to utilize data at all levels, from the provider, to local and national-level decision makers, in order to make evidence-based and needed adjustments to improve the quality of care provided. Over the last 7 years, the Doris Duke Charitable Foundation's African Health Initiative funded health systems strengthening projects at the facility, district, and/or provincial level to improve population health. Increasing data-driven decision making was a common strategy in Mozambique, Rwanda and Zambia. This paper describes the similar and divergent approaches to increase data-driven quality of care improvements (QI) and implementation challenge and opportunities encountered in these three countries. METHODS: Eight semi-structured in-depth interviews (IDIs) were administered to program staff working in each country. IDIs for this paper included principal investigators of each project, key program implementers (medically-trained support staff, data managers and statisticians, and country directors), as well as Ministry of Health counterparts. IDI data were collected through field notes; interviews were not audio recorded. Data were analyzed using thematic analysis but no systematic coding was conducted. IDIs were supplemented through donor report abstractions, a structured questionnaire, one-on-one phone calls, and email exchanges with country program leaders to clarify and expand on key themes emerging from IDIs. RESULTS: Project successes ranged from over 450 collaborative action-plans developed, implemented, and evaluated in Mozambique, to an increase from 80% of basic clinical protocols followed in intervention facilities in rural Zambia, and a shift from a lack of awareness of health data among health system staff to collaborative ownership of data and using data to drive change in Rwanda. CONCLUSION: Based on common successes across the country experiences, we recommend future data-driven QI interventions begin with data quality assessments to promote that rapid health system improvement is possible, ensure confidence in available data, serve as the first step in data-driven targeted improvements, and improve staff data analysis and visualization skills. Explicit Ministry of Health collaborative engagement can ensure performance review is collaborative and internally-driven rather than viewed as an external "audit.

Basic design and simulation of a SPECT microscope for in vivo stem cell imaging

The need to understand the behavior of individual stem cells at the various stages of their differentiation and to assess the resulting reparative action in pre-clinical model systems, which typically involves laboratory animals, provides the motivation for imaging of stem cells in vivo at high resolution. Our initial focus is to image cells and cellular events at single cell resolution in vivo in shallow tissues (few mm of intervening tissue) in laboratory mice and rates. In order to accomplish this goal we are building a SPECT-based microscope. We based our design on earlier theoretical work with near-field coded apertures and have adjusted the components of the system to meet the real-world demands of instrument construction and of animal imaging. Our instrumental design possesses a reasonable trade-off between field-of-view, sensitivity, and contrast performance (photon penetration). A layered gold aperture containing 100 pinholes and intended for use in coded aperture imaging application has been designed and constructed. A silicon detector connected to a TimePix readout from the CERN collaborative group was selected for use in our prototype microscope because of its ultra-high spatial and energy resolution capabilities. The combination of the source, aperture, and detector has been modeled and the coded aperture reconstruction of simulated sources is presented in this work

Development of novel composite data quality scores to evaluate facility-level data quality in electronic data in Kenya: A nationwide retrospective cohort study

BACKGROUND: In this evaluation, we aim to strengthen Routine Health Information Systems (RHIS) through the digitization of data quality assessment (DQA) processes. We leverage electronic data from the Kenya Health Information System (KHIS) which is based on the District Health Information System version 2 (DHIS2) to perform DQAs at scale. We provide a systematic guide to developing composite data quality scores and use these scores to assess data quality in Kenya. METHODS: We evaluated 187 HIV care facilities with electronic medical records across Kenya. Using quarterly, longitudinal KHIS data from January 2011 to June 2018 (total N = 30 quarters), we extracted indicators encompassing general HIV services including services to prevent mother-to-child transmission (PMTCT). We assessed the accuracy (the extent to which data were correct and free of error) of these data using three data-driven composite scores: 1) completeness score; 2) consistency score; and 3) discrepancy score. Completeness refers to the presence of the appropriate amount of data. Consistency refers to uniformity of data across multiple indicators. Discrepancy (measured on a Z-scale) refers to the degree of alignment (or lack thereof) of data with rules that defined the possible valid values for the data. RESULTS: A total of 5,610 unique facility-quarters were extracted from KHIS. The mean completeness score was 61.1% [standard deviation (SD) = 27%]. The mean consistency score was 80% (SD = 16.4%). The mean discrepancy score was 0.07 (SD = 0.22). A strong and positive correlation was identified between the consistency score and discrepancy score (correlation coefficient = 0.77), whereas the correlation of either score with the completeness score was low with a correlation coefficient of -0.12 (with consistency score) and -0.36 (with discrepancy score). General HIV indicators were more complete, but less consistent, and less plausible than PMTCT indicators. CONCLUSION: We observed a lack of correlation between the completeness score and the other two scores. As such, for a holistic DQA, completeness assessment should be paired with the measurement of either consistency or discrepancy to reflect distinct dimensions of data quality. Given the complexity of the discrepancy score, we recommend the simpler consistency score, since they were highly correlated. Routine use of composite scores on KHIS data could enhance efficiencies in DQA at scale as digitization of health information expands and could be applied to other health sectors beyondHIV clinics

risk factors associated with road traffic injuries in Mozambique: results of the 2016 INCOMAS study

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Early effects of COVID-19 on maternal and child health service disruption in Mozambique

This article is part of the Research Topic ‘Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'IntroductionAfter the World Health Organization declared COVID-19 a pandemic, more than 184 million cases and 4 million deaths had been recorded worldwide by July 2021. These are likely to be underestimates and do not distinguish between direct and indirect deaths resulting from disruptions in health care services. The purpose of our research was to assess the early impact of COVID-19 in 2020 and early 2021 on maternal and child healthcare service delivery at the district level in Mozambique using routine health information system data, and estimate associated excess maternal and child deaths.MethodsUsing data from Mozambique's routine health information system (SISMA, Sistema de Informação em Saúde para Monitoria e Avaliação), we conducted a time-series analysis to assess changes in nine selected indicators representing the continuum of maternal and child health care service provision in 159 districts in Mozambique. The dataset was extracted as counts of services provided from January 2017 to March 2021. Descriptive statistics were used for district comparisons, and district-specific time-series plots were produced. We used absolute differences or ratios for comparisons between observed data and modeled predictions as a measure of the magnitude of loss in service provision. Mortality estimates were performed using the Lives Saved Tool (LiST).ResultsAll maternal and child health care service indicators that we assessed demonstrated service delivery disruptions (below 10% of the expected counts), with the number of new users of family planing and malaria treatment with Coartem (number of children under five treated) experiencing the largest disruptions. Immediate losses were observed in April 2020 for all indicators, with the exception of treatment of malaria with Coartem. The number of excess deaths estimated in 2020 due to loss of health service delivery were 11,337 (12.8%) children under five, 5,705 (11.3%) neonates, and 387 (7.6%) mothers.ConclusionFindings from our study support existing research showing the negative impact of COVID-19 on maternal and child health services utilization in sub-Saharan Africa. This study offers subnational and granular estimates of service loss that can be useful for health system recovery planning. To our knowledge, it is the first study on the early impacts of COVID-19 on maternal and child health care service utilization conducted in an African Portuguese-speaking country

“Till the muddle in my mind have cleared awa”: can we help shape policy using systems modelling?

This paper considers how some well-documented deficiencies of mental models make it difficult to create effective policies, and suggests that systems modelling can begin to address this issue. To illustrate the argument three short cases are presented. These relate to specific domains but demonstrate how systems modelling can illuminate different general phenomena: effects on labour costs (unintended consequences and feedback); fishery management (accumulation and non-linearity) and child protection (worldviews and sense-making). Six levers for increasing the use of systems modelling in the policy arena are then discussed. The paper closes by emphasising the opportunities for systems modellers in the Anthropocene Era

Optimising implementation strategies of the first scaleup of a primary care psychological intervention for common mental disorders in Sub-Saharan Africa: a mixed methods study protocol for the optimised Friendship Bench (OptFB)

Introduction Common mental disorders (CMDs) are a leading cause of disability globally. CMDs are highly prevalent in Zimbabwe and have been addressed by an evidence-based, task-shifting psychological intervention called the Friendship Bench (FB). The task-shifted FB programme guides clients through problem-solving therapy. It was scaled up across 36 implementation sites in Zimbabwe in 2016. Methods and analysis This study will employ a mixed-method framework. It aims to: (1) use quantitative survey methodologies organised around the Reach, Effectiveness, Adoption and Implementation and Maintenance evaluation framework to assess the current scaleup of the FB intervention and classify 36 clinics according to levels of performance; (2) use qualitative focus group discussions and semistructured interviews organised around the Consolidated Framework for Implementation Research to analyse determinants of implementation success, as well as elucidate heterogeneity in implementation strategies through comparing high-performing and low-performing clinics; and (3) use the results from aims 1 and 2 to develop strategies to optimise the Friendship Bench intervention and apply this model in a cluster randomised controlled trial to evaluate potential improvements among low-performing clinics. The trial will be registered with the Pan African Clinical Trial Registry (www.pactr.org). The planned randomised controlled trial for the third research aim will be registered after completing aims one and two because the intervention is dependent on knowledge generated during these phases. Ethics and dissemination The research protocol received full authorisation from the Medical Research Council of Zimbabwe (MRCZ A/242). It is anticipated that changes in data collection tools and consent forms will take place at all three phases of the study and approval from MRCZ will be sought. All interview partners will be asked for informed consent. The research team will prioritise open-access publications to disseminate research results